Evolution & the UK’s National Health Service

It hasn’t been easy for your Curmudgeon, being virtually the only Republican on the sane side of the evolution-creationism debate. Not only are many popular bloggers clustered way over at the left end of the spectrum, but so are many of our readers. Adding to our difficulties is the fact that almost everyone in the latest crop of GOP presidential candidates is so crazy that we’re seriously thinking of changing our registration to “Independent” when the current wave of primaries ends — if the GOP candidate is a creationist.

[T]he person who finds creationism appealing — that is, one who is obsessed with the idea that some intelligent agency planned and caused our existence — is the same kind of person who is attracted to the idea of governmental controls over the population. Such controls may be imposed over private relationships, economic activities, education, religion, or whatever. For some it’s all of the above.

The common thread that unites the statist tyrant and the theocratic creationist is that they’re both authoritarians. Such people are the opposite of those who advocate reasoned liberty and all the other benefits derived from the principles of the Enlightenment — including limited government, free enterprise, and freedom of scientific inquiry.

What causes us to mention free enterprise again, knowing that it distresses so many of you? It’s because we found an excuse for doing so during one of our routine news sweeps. We present to you, dear reader, some excerpts from NHS reform is nothing new, but it’s about time leadership delivered, which appears at a British website called Health Service Journal (HSJ). The site describes itself as “the UK’s leading health service management and policy title.”

We know what you’re thinking: Have you lost your mind, Curmudgeon? Of all the dreary subjects in the world, why are you writing about the British health care system?

Relax, we’re not really doing that. This post is about evolution, and you’ll see that if you stay with us. Besides, British articles are fun. There’s not only the delightfully exotic spelling we always encounter there, we can look at the HSJ’s personnel page and learn that their editor’s first name is Alastair. That’s how we know that we’re not in Kansas, Toto. Not only that, the author of the essay about which we’re writing is Nigel Edwards.

So it is with a cheery wave to Nigel and Alastair — and all our readers in the UK, be they named Cedric, Cyril, Nevile, or Sherlock — that we turn to see what our cousins have written. Here are some excerpts, with bold font added by us:

When I was asked by HSJ to reflect on what I have learnt about in my 12 years at the NHS Confederation, I thought I would specifically reflect on the constant process of reform including at least two which were billed as a once in a generation chance to change the NHS.

Has Nigel learned anything in 12 years of bureaucratic activity? Let’s read on:

First, the policy making process is messy and this is true across time and different countries. While many of those involved are very talented and committed there are some persistent and repeating problems.

Nigel has encountered “persistent and repeating problems”? We’re shocked — shocked! Well, not really. Okay, dear reader, now we’re going to jump around to give you the flavor (or flavour) of what Nigel says, skipping over the boring parts that are specific to health care:

[F]ar too much weight has been put on the ability of the centre to design incentives and policies that will elicit a precise response. The potential for adverse unintended consequences and the fact that policy may work differently in different areas are still too often ignored.

[…]

We have seen many cases where policy makers try to solve the problems created by the previous reform that were hobbled by poor design, inaccurate diagnosis or evidence-lite policy ideas. … Unfortunately the words experiment and variation are rather unpopular with policy makers.

[…]

Almost every change mechanism available to policy makers in the UK has been used in the last 20 years … . This leaves a worrying impression of explanations being made up in a hurry after the event.

Here comes the good stuff. We’ll use some color (or colour) for emphasis:

A key lesson is having some clear principles for reform, supporting evidence, a strong narrative about why it is needed and how it will work and that allowing evolution and experiment generally works better than ‘intelligent design’ and the one-off creation of policy.

Aha! Eureka! By Jove, he’s got it!

That’s where Nigel should have stopped his article, because the solution to the UK’s health service problem is rather obvious (at least it is to us). Unfortunately we’re only about halfway through the article. From this point on, Nigel wanders way too much through the bureaucratic tangle in which he’s spent the past twelve years — as if he might find something of merit that might be salvaged. At the end he seems depressed, and he says:

Perhaps we can weather the storm, maybe the pressure for change on our current business models will take more time to be felt, but we need all the time we can get – and it’s probably later than we think.

That’s where we’re going to leave it. In the land of Darwin, the government is playing intelligent designer. They know it’s not working very well, but they can’t understand why.

Hey Nigel: Read your own paragraph again — the one we liked. Then think a wee bit more. You’re a bright fellow. Maybe you’ll figure it out. We’ll even give you a hint — What would Darwin do? Don’t see it yet? Okay, here’s one more hint: Privatize.

Oh that is SUCH a shame. Your posts are usually wonderfully curmudgeonly and I do so enjoy them.

I enjoyed this one.

Until the very last word.

Partial privatisation coupled with an ideological opposition to any kind of public sector (and chronic underfunding!) has been by far the biggest causal factor in the problems which have developed in the NHS. And the US health system is the laughing stock of the world; I’d rather be ill in Nigeria than North Carolina!

Adding to our difficulties is the fact that almost everyone in the latest crop of GOP presidential candidates is so crazy that we’re seriously thinking of changing our registration to “Independent” when the current wave of primaries ends — if the GOP candidate is a creationist.

The more I find out about health care in this country, the more I think privatization is nutty. Pharmaceutical and medical equipment providers should not be private. Doctors should be educated by the public. Health care should be driven by the public good, not by profit.

I know you will never agree to this, but it seems obvious to me. When pharmaceutical companies are not able to research and produce drugs that are not profitable but could help people, there is a problem with our system. When doctors cannot afford to keep prices low because they have enormous student loans, we have a problem. When people are bankrupted because of huge medical bills resulting from a serious illness or injury, we have a problem.

Health care is a public problem and needs to be solved by the public.

I know this is socialism, but our system stinks and shows no sign of getting better.

The existing privatized system in the U.S. produces has a long list of problems for which there is no market solution. Unlike other products and services, the consumer of medical care has very little influence over the cost or effectiveness of the service rendered. There is a wide range of factors, ranging from litigation risk, insurance reimbursement practices, the shift from GPs to specialists, lack of preventative or “wellness” care, fragmented state regulations hindering competition and economies of scale, drug costs, and on and on. Nowhere is there a market driver that rewards physicians and clinics or hospitals for the effective care of patients.

Perhaps the medical system could be restructured so that market drivers would serve to lower cost and improve care. However, that would require government action – there is no incentive within the system itself to make such a change. If there were market incentives already, we would have excellent care at a reasonable cost today and “Obama-care” would never have happened.

Calling something a “public problem” doesn’t change the laws of nature. Everything is a “public problem,” except maybe the color of the towels in your bathroom. Food is the biggest “public problem.” Everyone needs food. And it costs money to buy food. It’s an outrage that people run privately-owned farms for profit. The farms must be collectivized for the public good. Now! It’s the only way!

Yes, Lynn, I realize you didn’t call for collective farms — but seriously, where do you draw the line? Why is privately-run medicine somehow evil, but privately-run food isn’t?

I don’t think it’s so much an issue between privatizing or having a public institution that is hindering healthcare (or just about any endeavor) in the US. It’s the unabashed protection offered to the few who are managing to accumulate welath through these institutions. I’m not saying that earning honest money is bad, but something has gone seriously off kilter in the US, and it doesn’t seem to be getting better. We may need to solve that before we try to privatize anything just yet.

For many years I had labled myself a Republican, but I just can’t stand it anymore. In this day and age, it had become the Theocrat party, and I just can’t stomach that. Thankfully NH has a pretty open policy for us Independents who want to make our voices heard in whatever election is happening. 😉

It’s the unabashed protection offered to the few who are managing to accumulate welath through these institutions. I’m not saying that earning honest money is bad, but something has gone seriously off kilter in the US, and it doesn’t seem to be getting better.

If you know of some government-backed monopoly that’s squeezing us, I’m all for busting it up. What are you thinking of — the medical profession? If that’s it, the solution is to educate more doctors, not to drive the ones we’ve got out of the profession. I don’t know who else you’ve got in mind.

SC: Yes, Lynn, I realize you didn’t call for collective farms — but seriously, where do you draw the line?

Where you think it’s best to draw it, of course. Conservatives do the same thing – you don’t hear many conservative candidates calling for the abolishment of medicare because it puts us on the slippery slope to Marxism. The difference is not so much “total free market capitalism in every way” vs. “any smidgen of socialism.” Pretty much everyone is on the right-hand side of that vs. Its when and where you place regulation and social redistribution. In the food area, for instance, I think rational people can support things like food stamps without thinking it’s going to lead to total elimination of private food choice. And the strongest proponents of government subsidies of the farm industry are the GOP, even though this is redistributon and market regulation. I.e. socialism.

Both liberals and conservatives ask “how much socialization is needed in each sector to provide every citizen with (what the speaker thinks is) a necessary level of support.” The conservative answer in most cases is going to be lower than the liberal one. But if you think your answer is “zero across the board – anything else is a slippery slope to marxism” you are probably fooling yourself.

Come on over to the Independent side [been there for many years – main drawback is not being able to vote in primaries in Colorado]. Related to eryops comment, one of your first missions is to end crop subsidies!

eryops says:
“isn’t food subsidized to a point where the average person can afford it?”

As Douglas E points out, about the only food subsidies are going to the farmers in the form of crop subsidies and price supports. These have the effect of raising food costs to the consumer, not lowering them.

In answer to Lynn’s comment about public problems being solved by the public: the set of market failures that cripple the U.S. healthcare system are caused by the actions of both public and private actors. Medicine by civil servant may have attractions, but it has it’s own problems, as the NHS shows. “Public service” is a noble ideal, but in practice, the “public servants” are as capable of acting as a self-serving interest group as anyone else.

First, there aren’t “food subsidies”. Almost all of them go for corn, cotton, wheat, rice, and soybeans. As pointed out above, the purpose is to keep prices high–Americans pay extra for food twice, once for the artifically high prices and once for the subsidies (for those Americans who pay Federal taxes anyway). There are also mandates–like the ethanol-in-gasoline mandate–and tariffs, like the tariffs on sugar, that keep prices high and restrict competition.

The subsidy programs give farmers extra money for their crops and guarantee a price floor. For instance in the 2002 Farm Bill, for every bushel of wheat sold, farmers were paid an extra 52 cents and guaranteed a price of 3.86 from 2002–03 and 3.92 from 2004–2007.[16] That is, if the price of wheat in 2002 was 3.80 farmers would get an extra 58 cents per bushel (52 cents plus the $0.06 price difference).

And thus the government achieves what the free market cannot–high prices AND overproduction AND artifical scarcity (most corn is used for feed and ethanol).

Second, the US is far from a free market in health care. You have the government paying for a large chunk of it through Medicare and Medicaid, and distorting the market that way. You have regulations on what services doctors can provide and who they must provide them to. You have regulations on how much of your own income you can spend on health care and in what ways you can spend it. (My dear wife and I have a health savings account–every dollar in it is a dollar we contributed out of our own income, and every time we turn around there are new restrictions on how we can spend that money.) New drugs and treatments require government approval, and the government also finances research into worthless alternative treatments. To buy drugs without a prescription is a CRIME. Insurance is for most of us is tied to employment, and is also highly regulted in price and coverage. Etc.

Furthermore, the US health care system, as imperfect as it is universally acknowledged to be, is far from a laughingstock as some of our foreign commenters who rely on caricatures for their information seem to think. For example, the bulk of new drug research is done here. Infant mortality in the US is the same as in Europe*, despite our much higher rates of premature births and VERY different demographics, and premature infant survival is much better here. Cancer survival rates are better. Wait times for treatments are shorter. Etc.

Certainly there is much room for improvement, but health care in the US is already a highly regulated market, and is on the whole no worse, if little better, than in other developed nations.

We can afford to help poor people get the care they need without dragooning everyone into a nationalized system, just like we feed poor people without a nationalized system of farms and we house poor people without a nationalized system of housing.

But we have to be prepared for the unintended consequences because the law of supply and demand cannot be repealed. As college tution trends demonstrate, when you pay people to buy something the price goes way up, because the demand curve has been shifted.

On moral grounds I think free market solutions are better, because individuals can make their own choices about what they want for their money. Rich people can get better outcomes they may not deserve, but under government-run systems there is also unfariness–politically connected and famous people people get benefits others don’t.

*Challenge me on the infant mortality stats, by all means–all I ask is that you don’t throw me in that briar patch…

Although my dad made a fair amount of money raising corn, beans and chickens as well as founding and running a successful crop fertilizer company, at 95 he still has enough sense to scorn the food-for-fuel programs. While he appreciates that the farmers are doing quite well with $7/bushel corn, he also understands that it is an artificial and unedifying system.